The US health care picture: a sketch

The United States spends over $2.3 trillion on health care, roughly 16% of GDP.   $7000 per capita, compared to $3500 in other countries in 2006.  But we aren’t getting what we pay for, at least not on a system-wide basis.

Worldwide, we rank 29th in infant mortality, 48th in life expectancy, and 19th out of 19 industrialized countries in preventable deaths.  The number of uninsured – 45.7 million by recent counts – dropped slightly in 2007 but will definitely increase because of the financial crisis.

The cost to access health care is inhibitory for many individuals and families.  Many aren’t filling needed prescriptions.

About one in three Americans now report their family has had problems paying medical bills in the past year, up from about a quarter saying the same two years ago.  Almost one in five (18%) of Americans report household problems with medical bills amounting to more than $1,000 in the past year.

Nearly half (47%) of the public reports someone in their family skipping pills, postponing  or cutting back on medical care they said they needed in the past year due to the cost of care.  For example, just over one-third say they or a family member put off or postponed needed care and three in ten say they skipped a recommended test or treatment – increases of seven percentage points from last April’s tracking poll which asks the same question.

The uninsured drive up the cost of health care for everybody, as someone has to pay for the annual $56 billion in uncompensated care.  The common story is that the uninsured wait until a medical condition escalates in severity and then go to the ER, where hospitals are obligated to treat them.   And now, with the recession, ERs (already overcrowded) are becoming even more burdened.   And overcrowded ERs leads to boarding (treating patients in ER hallways) which sacrifices the quality of care.   This isn’t sustainable.  As the American College of Emergency Physicians said, the US system of ERs is in “serious condition.”

Paying patients subsidize Medicare, etc., patients, but now there are fewer paying patients so hospitals themselves are struggling to survive.  15 hospitals have closed in the past 8 years in Los Angeles County.  Public hospitals are on the verge of shutting down.

Now there is a shortage of providers of care.  600 openings for physicians in Wisconsin alone.  Half of those currently practicing in primary care say they want to quit within 3 years.  By 2025, the American Association of Medical Colleges estimates, the shortage will reach 124,000.  Assuming the utilization is the same as today.  With increased usage (emphasizing preventive care, expanding access/coverage), the shortage will increase by 31,000.  Increasing the size of medical school classes has only put a slight dent in this problem; current medical students often steer clear of primary care.

Medical students don’t overwhelmingly go into primary care, because they can’t afford to practice in the field.  Medicare reimbursements are dismal, driving many doctors to no longer accept it so their practice can remain afloat, and hospitals are biting the bullet with the underpayments (which shifts costs to private insurers and employers, increasing premiums).  Others are cutting services, including children’s vaccinations.  And the tanking economy only leads to more cuts.  I won’t even get into the problem of (micro)managed care.

Those who have trouble accessing their physicians because of the shortage (insured patients who are dismayed by the wait, Medicare recipients who are dismayed by the dearth of primary care providers accepting Medicare, etc.)…guess where they go for their care?  The ER.

The US health care system is in the midst of a perfect storm.  Allow me to be a bit simplistic:  Rising costs of health care exacerbates the effects of the failing economy –> decrease in employer-sponsored insurance or a loss of a job and the insurance that came with it  –> more uninsured and underinsured –> greater demand on Medicare/Medicaid.  But these programs themselves are financially strapped and looking to save money –> low physician reimbursements –> fewer physicians accepting Medicare or insurance in general (what’s the point of having insurance if you can’t find a doctor to treat you?).  The shortage of primary care providers and shuttering of hospitals ultimately leads to less access to health care.

This cursory glance at the problems afflicting the health care system doesn’t do justice to the complexities of the situation (there is some great literature on the subject).  I feel like we’re on borrowed time, like the system could collapse around us any moment now.  Health care reform might have fallen off the front pages because of the economic crisis, but if the Obama administration doesn’t do something soon, this perfect storm might blow down this house of cards.

Tags: access to health care, health care, health insurance, Medicare, physician shortage